Predisposing factors for hepatocellular carcinoma recurrence following initial remission after transcatheter arterial chemoembolization

Tumor Growth Pattern and Intra- and Peritumoral Radiomics Combined for Prediction of Initial TACE Outcome in Patients with Primary Hepatocellular Carcinoma

Purpose

Non-invasive methods are urgently needed to assess the efficacy of transarterial chemoembolization (TACE) and to identify patients with hepatocellular carcinoma (HCC) who may benefit from this procedure. This study, therefore, aimed to investigate the predictive ability of tumor growth patterns and radiomics features from contrast-enhanced magnetic resonance imaging (CE-MRI) in predicting tumor response to TACE among patients with HCC.

Patients and Methods

A retrospective study was conducted on 133 patients with HCC who underwent TACE at three centers between January 2015 and April 2023. Enrolled patients were divided into training, testing, and validation cohorts. Rim arterial phase hyperenhancement (Rim APHE), tumor growth patterns, nonperipheral washout, markedly low apparent diffusion coefficient (ADC) value, intratumoral arteries, and clinical baseline features were documented for all patients. Radiomics features were extracted from the intratumoral and peritumoral regions across the three phases of CE-MRI. Seven prediction models were developed, and their performances were evaluated using receiver operating characteristic (ROC) and decision curve analysis (DCA).

Results

Tumor growth patterns and albumin-bilirubin (ALBI) score were significantly correlated with tumor response. Tumor growth patterns also showed a positive correlation with tumor burden (r = 0.634, P = 0.000). The Peritumor (AUC = 0.85, 0.71, and 0.77), Clinics_Peritumor (AUC = 0.86, 0.77, and 0.81), and Tumor_Peritumor (AUC = 0.87, 0.77, and 0.80) models significantly outperformed the Clinics and Tumor models (P < 0.05), while the Clinics_Tumor_Peritumor model (AUC = 0.88, 0.81, and 0.81) outperformed the Clinics (AUC = 0.67, 0.77, and 0.75), Tumor (AUC = 0.78, 0.72, and 0.68), and Clinics_Tumor (AUC = 0.82, 0.83, and 0.78) models (P < 0.05 or 0.053, respectively). The DCA curve demonstrated better predictive performance within a specific threshold probability range for Clinics_Tumor_Peritumor.

Conclusion

Combining tumor growth patterns, intra- and peri-tumoral radiomics features, and ALBI score could be a robust tool for non-invasive and personalized prediction of treatment response to TACE in patients with HCC.

Tumor Burden Score and Serum Alpha-fetoprotein Subclassify Intermediate-Stage Hepatocellular Carcinoma

BACKGROUND

Resection of Barcelona Clinic Liver Cancer (BCLC) intermediate-stage hepatocellular carcinoma (HCC) remains controversial. While not recommended by the BCLC algorithm, some patients may indeed benefit from hepatectomy. We sought to identify that subset of patients who might derive long-term survival benefit from resection.

METHODS

Intermediate-stage HCC patients who underwent curative-intent resection were identified from an international multi-institutional database. Factors associated with long-term prognosis were identified using multivariate analysis and a risk score was developed and assessed.

RESULTS

Among 194 patients, most individuals had two tumors (n = 123, 63.4%) with a median size of 6.0 cm (IQR, 4.0-8.4) for a median tumor burden score (TBS) of 6.5 (IQR, 5.0-9.1); median alpha-fetoprotein (AFP) was 23.9 ng/mL (IQR, 5.0-503.2), and median overall survival (OS) was 69 months (IAR, 60.7-77.3). Factors associated with OS included AFP (referent ≤ 20 ng/mL, > 20 ng/mL: HR 1.78 95%CI, 1.09-2.89) and TBS (referent TBS ≤ 8.0, TBS > 8.0: HR 1.72 95%CI, 1.07-2.75). While 71 (36.6%) patients had neither risk factor, 79 (40.7%) and 44 (22.7%) had 1 or 2, respectively. A simplified score stratified patients relative to recurrence-free survival (RFS) (0: 33.6% vs. 1: 18.0% vs. 2: 14.7%) (AUC 0.60) and recurrence time (i.e., < 6 months after surgery) (0: 21.3% vs. 1: 43.1% vs. 2: 68.6%) (AUC 0.69) (both p < 0.001). Of note, a higher score was also associated with incrementally worse 5-year OS (0: 68.1% vs. 1: 61.0% vs. 2: 29.9%) (AUC 0.62) (p < 0.001).

CONCLUSION

Long-term OS and RFS outcomes varied considerably. Using a simple risk score, patients with low AFP and low TBS were identified as the subset of individuals most likely to benefit from resection.

Transarterial Chemoembolization and Unresectable Hepatocellular Carcinoma: A Narrative Review

Hepatocellular carcinoma (HCC) is an aggressive tumor, and even with the breakthrough in preventive strategies, and new diagnostic and treatment modalities, incidence and fatality rates continue to climb. Patients with HCC are most commonly diagnosed in the later stage, where the disease has already advanced, making it impossible to undertake potentially curative surgery. Transarterial chemoembolization (TACE) is a locoregional therapy regarded as a first-line treatment in patients with intermediate-stage HCC (Barcelona clinical liver cancer {BCLC}-B). TACE is a minimally invasive and non-surgical procedure that combines local chemotherapeutic drug administration with embolization to treat HCC. It helps limit tumor growth, preserve liver function, and increase overall and progression-free survival in patients with intermediate-stage HCC. This article has reviewed the efficacy, survival, limitations, and overall benefit of TACE in patients with unresectable HCC. This article has also discussed the effectiveness of TACE for neoadjuvant chemoembolization and the use of TACE with combination therapies.

Gadoxetic Acid-Enhanced MRI Features for Predicting Treatment Outcomes of Early Hepatocellular Carcinoma (< 3 cm) After Transarterial Chemoembolization

RATIONALE AND OBJECTIVES

Magnetic resonance imaging (MRI) is the most useful imaging tool for small hepatocellular carcinoma (HCC) evaluation. Patients undergoing transarterial chemoembolization (TACE) might have predictive imaging prognostic factors. This study aimed to find predictive gadoxetic acid (GA)-enhanced MRI features that affect tumor response and outcomes in patients with early HCC who underwent conventional TACE.

MATERIALS AND METHODS

Among patients who underwent conventional TACE as a first-line treatment for Barcelona clinic liver cancer stage 0 or A (<3 cm), 135 patients who underwent GA-enhanced MRI before treatment were included in this retrospective study. The patients' pretreatment clinical characteristics and MRI features were evaluated. Post-treatment tumor response, progression-free survival (PFS), and overall survival (OS) were also investigated.

RESULTS

The median follow-up period was 47 (range: 7-133) months, with 90 (67%) patients showing complete remission (CR) at the 1-month follow-up after TACE. Tumor number (odds ratio [OR] 0.602, 95% confidence interval [CI]: 0.375-0.967), central location (OR: 0.349, 95% CI: 0.145-0.837) were inversely associated with CR achievement. Median PFS and OS time were 22 (range: 1-133) and 67 (range: 7-133) months, respectively. The MRI features affecting poor survival outcomes were tumor number (PFS: hazard ratio [HR]=1.444, 95% CI=1.124-1.854; OS: HR=1.459, 95% CI=1.018-2.090), central location (PFS: HR=1.664, 95% CI=1.038-2.667; OS: HR=1.890, 95% CI=1.021-3.497), and marginal irregularity (PFS: HR=3.099, 95% CI=1.953-4.979; OS: HR=1.985, 95% CI=1.084-3.634).

CONCLUSION

Multiplicity, central location, and marginal irregularity of HCC on GA-enhanced MRI were significant factors associated with poor prognosis of patients with early HCC after conventional TACE.

Comparison of Ablation Area and Change in Functional Liver Reserve after Radiofrequency Ablation for Hepatocellular Carcinoma Using the arfa® and VIVA® Systems

Radiofrequency ablation (RFA) is recommended in Japan for patients with hepatocellular carcinomas (HCCs) one to three in number and ≤3 cm in size. The arfa^® and VIVA^® RFA systems are widely used for patients with HCC and this retrospective observational study aims to compare their performances. The study included 365 patients with HCCs one to three in number and ≤3 cm in size who underwent RFA using the arfa^® system (arfa^® group) or the VIVA^® system (VIVA^® group). The total bilirubin (T-Bil) level after RFA was higher in the arfa^® group than in the VIVA^® group. With a 3-cm electrode needle, the longest diameter (Dmax) and the shortest diameter were analyzed and found to be greater in the arfa^® group than in the VIVA^® group. Furthermore, Dmax with the 2.5-cm electrode needle was greater in the arfa^® group than in the VIVA^® group. Statistically significant differences in the ablation area and in the T-Bil value after RFA were observed between the groups; however, these differences are not considered clinical problems because the difference in the ablation area was only slight and the Child–Pugh score was the same between the groups. Thus, hepatologists can use either of the RFA systems based on their preference.

Prediction of transarterial chemoembolization refractoriness in patients with hepatocellular carcinoma using imaging features of gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND

Repeated transarterial chemoembolization (TACE) can be associated with loss of its efficacy and subsequent tumor progression.

PURPOSE

To identify features of gadoxetic acid-enhanced magnetic resonance imaging (MRI) associated with TACE refractoriness and to develop a prediction model for estimating the risk of TACE refractoriness.

MATERIAL AND METHODS

Among 1025 patients with intermediate-stage hepatocellular carcinoma (HCC) who underwent TACE as a first-line treatment during 2010-2017, 427 patients who underwent preoperative gadoxetic acid-enhanced MRI were analyzed. According to the date of initial TACE, patients were divided into the development cohort (n = 211) and the test cohort (n = 216). TACE refractoriness was determined according to the Japan Society of Hepatology guidelines. Univariable and multivariable analyses were performed to investigate the association between clinical/MRI features and TACE refractoriness. The performance of the prediction model was internally and externally assessed using the C-index of discrimination and a Hosmer-Lemeshow goodness-of-fit test for calibration.

RESULTS

By analyzing 427 patients, we constructed a prediction model with the following independent features associated with TACE refractoriness: maximum tumor size; tumor number; peritumoral hypointensity on hepatobiliary phase (HBP); and the presence of non-hypervascular hypointense nodule on HBP. This system enabled the prediction of TACE refractoriness in the development cohort (C-index, 0.796) and the test cohort (C-index, 0.738) with good discrimination and calibration abilities.

CONCLUSION

The prediction model based on gadoxetic acid-enhanced MRI features in addition to the known predictors including tumor size and number can be used to estimate the risk of TACE refractoriness in patients with intermediate-stage HCC.

The Combination of Albumin-Bilirubin Score and Prothrombin Time Is a Useful Tool for Predicting Liver Dysfunction after Transcatheter Arterial Chemoembolization in Child-Pugh Class A Patients with Hepatocellular Carcinoma within Up-to-Seven Criteria

Mortality and recurrence rates of hepatocellular carcinoma (HCC) are high. Recent studies show that for patients with HCC beyond up-to-seven criteria, treatment with molecular-targeted agents (MTAs) is recommended because the treatment efficiency of transcatheter arterial chemoembolization (TACE) is poor; further, TACE increases decline in liver function. However, the relationship between TACE and liver function decline in patients with HCC within up-to-seven criteria has not been clarified. Hence, we aimed to investigate this relationship. This retrospective observational study included 189 HCC tumors within up-to-seven criteria in 114 Child–Pugh class A patients. Twenty-four (12.7%) tumors were changed from Child–Pugh class A to B after TACE, and 116 (61.4%) tumors exhibited recurrence within 6 months after TACE. Prothrombin time (PT) and albumin–bilirubin (ALBI) score before TACE were significantly associated with liver dysfunction from Child–Pugh class A to B. The combination of PT and ALBI score before TACE had high predictive ability for liver dysfunction from Child–Pugh class A to B after TACE (specificity = 100%, sensitivity = 91.7%). The combined use of pre-TACE PT and ALBI score has a high predictive ability for liver dysfunction after TACE for Child–Pugh class A patients with HCC within up-to-seven criteria.

Complete response at first transarterial chemoembolization predicts favorable outcome in hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the mainstay of treatment for patients with intermediate/advanced stage or unresectable hepatocellular carcinoma (HCC). Despite the palliative nature of TACE treatment, embolizing the tumor feeding vessels and leading to progressive tumor necrosis, complete response (CR) after TACE could still be observed in a certain population. Thus, this study aimed to investigate both the predictors for CR and the long-term prognosis of the patients with CR after TACE. The study recruited new diagnosed HCC patients initially treated with TACE from 2010 to 2013. Post TACE response was assessed by scheduled image studies according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Then, pre-TACE factors were compared between patients with and without CR. After the first session of TACE, 22.3% of the 669 TACE treated patients achieved CR. During a median of 26.6 months follow-up, patients with CR had better overall survival than those without (median: 35.8 vs. 24.0 months, P<0.001). By multivariate logistic regression analysis, Child-Turcotte-Pugh class B (OR: 0.419, P=0.005), tumor burden beyond up-to-7 criteria (OR: 0.118, P<0.001), bilobar tumor extent (OR: 0.236, P<0.001), higher alpha-fetoprotein (AFP) level (≥20 ng/ml, OR: 0.614, P=0.039) and higher platelet counts (>150 k/μl, OR: 0.482, P=0.002) were unfavorable predictors for CR after first TACE. In addition, macrovascular invasion (HR: 3.113, P=0.001) and higher AFP levels (≥15 ng/ml, HR: 2.601, P=0.007) were predictors for early HCC recurrence whereas diabetes mellitus (DM) (HR: 2.166, P=0.006) was the only significant predictor for late HCC recurrence in CR patients. In conclusion, more than one-fifth of HCC patients achieved CR after first TACE and these patients had favorable prognosis. Furthermore, tailored post-TACE follow-up strategies shall be considered in patients with different risk factors of early or late recurrence after CR.

Occurrence of Vascular Lake Phenomenon Before Embolization for the Prediction of Lipiodol Uptake for Intermediate-Stage Hepatocellular Carcinoma Patients that Underwent cTACE

PURPOSE

To compare Lipiodol uptake and tumor response in intermediate-stage hepatocellular carcinoma (HCC) with and without pre-embolization vascular lake phenomenon (VLP) and to identify the incidence and predictive factors of this phenomenon, in patients treated by conventional transarterial chemoembolization (cTACE).

MATERIALS AND METHODS

This retrospective study included 151 consecutive patients with intermediate HCC totaling 232 nodules, who underwent cTACE from June 2015 to October 2018. Patients were divided into two groups according to the presence of VLP before embolization. Initial Lipiodol uptake was assessed using post-cTACE computed tomography (CT) within 1-1.5 months after cTACE. Enhanced CT or magnetic resonance imaging was performed at 6 months after the procedure to assess local recurrence and distant metastasis.

RESULTS

The VLP was demonstrated in 21.85% (33/151) patients and 16.81% (39/232) nodules on the super-selective angiography. On nodule-based analysis, significantly better Lipiodol uptake (p < 0.001) and higher ORR (60.61% vs. 26.49%, p < 0.001) and DCR (87.88% vs. 51.66%, p < 0.001) were observed in the VLP group compared to the non-VLP group. The multivariate logistic regression analysis showed that the presence of VLP (OR 6.431, 95% CI 2.495-16.579) might be a predictive factor for better Lipiodol uptake. Univariate and multivariate logistic regression analysis showed that poor differentiation of tumor (OR 6.397, 95% CI 2.804-19.635) remained predictive for the VLP.

CONCLUSION

The incidence of VLP before embolization is 21.19%. The presence of VLP is well correlated with tumor Lipiodol uptake after cTACE and may be a new predictive factor for evaluation of cTACE efficacy and prognosis of intermediate HCC.

Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation

BACKGROUND

Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion.

METHOD

Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival.

RESULTS

Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively.

CONCLUSION

Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.

A Novel Scoring System for Patients with Recurrence of Hepatocellular Carcinoma After Undergoing Minimal Invasive Therapies

Background

The higher recurrence rate of hepatocellular carcinoma (HCC) needs to be urgently controlled. However, definitive markers are lacking for patients with recurrence of HCC after undergoing minimal invasive therapies-local ablation combined with transcatheter arterial chemoembolization (TACE).

Materials and methods

Demographic and clinicopathological data of 234 subjects receiving combined therapies as the initial treatment were retrospectively analyzed. Univariate and multivariate Cox regression analysis was used to assess independent risk factors of recurrence. Selected variables were divided into low-, intermediate-, and high-risk groups of recurrence according to the scores assigned to them based on their respective hazard ratio (HR) values. The area under the curve (AUC) was used to evaluate the predictive value of the scoring system. Cumulative recurrence-free survival (RFS) and overall survival rates were calculated by the Kaplan-Meier estimator. Finally, a correlation analysis was performed on demographic and clinical data among the three groups.

Results

The AUC of predicting 1-, 2-, and 3-year recurrence rates was 0.680, 0.728, and 0.709, respectively. The cumulative RFS rate in the low-risk group at 1, 2, and 3 years after undergoing combined treatments was 4%, 12.2%, and 30.6%, while that in the intermediate-risk group and high-risk group was 23.4%, 51.6%, 60.0%, and 47.3%, 78.2%, 83.6%, respectively. Gamma-glutamyltransferase (γ-GT), blood urea nitrogen (BUN), and total cholesterol (TC) levels among the three groups were statistically different.

Conclusion

The scoring system of the present study for patients with the recurrence of HCC after undergoing TACE combined with local ablation may help physicians make a reasonable clinical decision, providing ideal management for diagnosis and treatment.

MRI-Based Radiomics: Associations With the Recurrence-Free Survival of Patients With Hepatocellular Carcinoma Treated With Conventional Transcatheter Arterial Chemoembolization

BACKGROUND

Preoperative estimation of hepatocellular carcinoma (HCC) recurrence after conventional transcatheter arterial chemoembolization (c-TACE) is crucial for subsequent follow-up and therapy decisions.

PURPOSE

To evaluate the associations of radiomics models based on pretreatment contrast-enhanced MRI, a clinical-radiological model and a combined model with the recurrence-free survival (RFS) of patients with HCC after c-TACE, and to develop a radiomics nomogram for individual RFS estimations and risk stratification.

STUDY TYPE

Retrospective.

POPULATION

In all, 184 consecutive HCC patients.

FIELD STRENGTH/SEQUENCE

1.5T or 3.0T, including T₂ WI, T₁ WI, and contrast-enhanced T₁ WI.

ASSESSMENT

All HCC patients were randomly divided into the training (n = 110) and validation datasets (n = 74). Radiomics signatures capturing intratumoral and peritumoral expansion (1, 3, and 5 mm) were constructed, and the radiomics models were set up using least absolute shrinkage and selection operator (LASSO) Cox regression. Clinical-radiological features were identified by univariate and multivariate Cox regression. The clinical-radiological model and the combined model fusing the radiomics signature with the clinical-radiological risk factors were developed by a multivariate Cox proportional hazard model. A radiomics nomogram derived from the combined model was established.

STATISTICAL TESTS

LASSO Cox regression, univariate and multivariate Cox regression, Kaplan-Meier analysis were performed. The discrimination performance of each model was quantified by the C-index.

RESULTS

Among the different peritumoral expansion models, only the 3-mm peritumoral expansion model (C-index, 0.714) showed a comparable performance (P = 0.4087) to that of the portal venous phase intratumoral model (C-index, 0.727). The combined model showed the best performance and the C-index was 0.802. Kaplan-Meier analysis showed that the cutoff values of the combined model relative to a median value (1.7426) perfectly stratified these patients into high-risk and low-risk subgroups.

DATA CONCLUSION

The combined model is more valuable than the clinical-radiological model or radiomics model alone for evaluating the RFS of HCC patients after c-TACE, and the radiomics nomogram can be used to preoperatively and individually estimate RFS.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage: 4 J. Magn. Reson. Imaging 2020;52:461-473.

Preoperative MRI features and clinical laboratory indicators for predicting the early therapeutic response of hepatocellular carcinoma to transcatheter arterial chemoembolization combined with High-intensity focused ultrasound treatment

OBJECTIVES

To evaluate the value of preoperative MRI features and laboratory indicators in predicting the early response of hepatocellular carcinoma (HCC) to transcatheter arterial chemoembolization (TACE) combined with high-intensity focused ultrasound (HIFU) treatment and to establish a preoperative prediction model.

METHODS

A total of 188 patients with 223 tumors who underwent TACE/HIFU treatment from January 2011 to June 2017 were included. Tumors were divided into three groups (< 2 cm, 2 - 5 cm,> 5 cm) and classified as non-complete response (NCR) and complete response (CR) cohorts according to the Response Evaluation Criteria in Cancer of the Liver (RECICL) 2015 revised version. Univariate analysis and multivariate logistic regression analysis were used to determine independent predictors, and receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic power of each predictor. The prediction model was derived on the β coefficient of the multivariate regression analysis of the predictors.

RESULTS

Irregular margins in the 2 - 5 cm group were closely related to early NCR. Irregular margins, arterial peritumoral enhancement and abnormal alpha-fetoprotein (AFP) were independent predictors of early NCR in the > 5 cm group. The prediction model of this group suggests that irregular margins combined with arterial peritumoral enhancement and abnormal AFP combined with irregular margins and arterial peritumoral enhancement predict an increased risk of early NCR.

CONCLUSION

Irregular margins of 2 - 5 cm tumors and irregular margins, arterial peritumoral enhancement, and abnormal AFP of tumors > 5 cm can be applied to predict the early response of HCC to TACE/HIFU treatment.

ADVANCES IN KNOWLEDGE

TACE combined with HIFU treatment may be able to significantly improve survival in patients with advanced HCC. Conventional MRI features and laboratory indicators are readily available without complex post-processing. It is feasible to predict the response of HCC after TACE/HIFU treatment based on preoperative conventional MRI features and laboratory indicators, the combination of multiple features predicts high-risk of non-complete response.

Reason of Discontinuation After Transarterial Chemoembolization Influences Survival in Patients with Hepatocellular Carcinoma

Background

Transarterial chemoembolization (TACE) for intermediate-stage hepatocellular carcinoma (HCC) is often repeated until unTACEable progression (UTP) occurs. There is little data on the various reasons for stopping TACE and its consequences for subsequent treatment and survival.

Aim

To assess the impact of the various reasons of UTP on survival and consequences for subsequent treatments.

Methods

Consecutive HCC patients who underwent TACE between 2003 and 2016 were analyzed retrospectively for the reason of TACE discontinuation. UTP was defined according to the EASL guidelines, considering radiological pattern of progression, liver function and performance status (PS). Overall and post-progression survival (OS, PPS) for different reasons of TACE discontinuation were compared. The correlation between time to untreatable progression by chemoembolization (TTUPc) and OS was analyzed.

Results

One hundred and sixty-six patients (BCLC-A 40%, BCLC-B 54%, BCLC-C: 7%) were included, undergoing a median of 2 TACE procedures with a median OS of 22.1 months (95% CI 17.4–26.7). UTP occurred in 116 patients (70%) after a median TTUPc of 11.6 months (95% CI 7.8–15.4). There was a strong positive correlation (ρ = 0.816, p < 0.001) between TTUPc and OS. The main reason of UTP was radiological progression (61%), which was mostly intrahepatic (75%). Hepatic decompensation and worsening of PS were independent predictors of OS and PPS.

Conclusion

The majority of HCC patients treated with TACE have UTP due to intrahepatic tumor progression with preserved liver function and PS, making them potential candidates for subsequent liver-directed or systemic treatment. TTUPc may be a valuable surrogate endpoint for OS in patients treated with TACE.

Level of Evidence

Level II, prognosis study.

Electronic supplementary material

The online version of this article (10.1007/s00270-018-2118-6) contains supplementary material, which is available to authorized users.

Five-year outcome of conventional and drug-eluting transcatheter arterial chemoembolization in patients with hepatocellular carcinoma

Background

Currently, no standard of care or therapies have been established for patients with advanced HCC. We evaluated the efficacy and safety of conventional transarterial chemoembolization using gelatin sponges or microspheres plus lipiodol-doxorubicin (cTACE) and TACE with doxorubicin-loaded drug eluting beads (DEB-TACE).

Methods

This retrospective study included 273 patients who received cTACE (n = 201) or DEB-TACE. Tumor response, survival, and adverse events were evaluated over a 5-year follow-up period.

Results

During 5-year follow-up, a greater percentage of patients treated with cTACE died than those treated with DEB-TACE (76.1% vs. 66.7%) (P = 0.045). At the last evaluation, all surviving patients had disease progression and no differences were seen between treatment groups. However, the time to disease progression differed between groups; median time to disease progression was 11.0 months for cTACE and 16.0 months for DEB-TACE (P = 0.019). The median survival time was 37 months in both treatment groups. No significant differences were observed between cTACE and DEB-TACE therapies in subgroups of patients with BCLC stage A or stage B + C either in survival time or time to disease progression (P values > 0.05). No significant differences were observed in survival status or disease progression between cTACE and DEB-TACE in patient subgroups with either tumor number > 5 or with the sum of the diameter of largest five HCC tumors being > 7 cm.

Conclusions

DEB-TACE demonstrates greater long-term benefits than cTACE in treating treatment-naïve patients with HCC. Results of this long-term study support the use of DEB-TACE in treating HCC.